Health Insurance and Mental Health Services

Q: How does the Affordable Care Act help people with mental health issues?

Answer: The Affordable Care Act provides one of the largest expansions of mental health and substance use disorder coverage in a generation, by requiring that most individual and small employer health insurance plans, including all plans offered through the Health Insurance Marketplace cover mental health and substance use disorder services. Also required are rehabilitative and habilitative services that can help support people with behavioral health challenges. These new protections build on the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) provisions to expand mental health and substance use disorder benefits and federal parity protections to an estimated 62 million Americans.

Because of the law, most health plans must now cover preventive services, like depression screening for adults and behavioral assessments for children, at no additional cost. And, as of 2014, most plans cannot deny you coverage or charge you more due to pre-existing health conditions, including mental illnesses.

Answer: As of 2014, most individual and small group health insurance plans, including plans sold on the Marketplace are required to cover mental health and substance use disorder services. Medicaid Alternative Benefit Plans also must cover mental health and substance use disorder services. These plans must have coverage of essential health benefits, which include 10 categories of benefits as defined under the health care law. One of those categories is mental health and substance use disorder services. Another is rehabilitative and habilitative services. Additionally, these plans must comply with mental health and substance use parity requirements, as set forth in MHPAEA, meaning coverage for mental health and substance abuse services generally cannot be more restrictive than coverage for medical and surgical services.

Q: How do I find out if my health insurance plan is supposed to be covering mental health or substance use disorder services in parity with medical and surgical benefits? What do I do if I think my plan is not meeting parity requirements?

Answer: In general, for those in large employer plans, if mental health or substance use disorder services are offered, they are subject to the parity protections required under MHPAEA. And, as of 2014, for most small employer and individual plans, mental health and substance use disorder services must meet MHPAEA requirements.

If you have questions about your insurance plan, we recommend you first look at your plan’s enrollment materials, or any other information you have on the plan, to see what the coverage levels are for all benefits. Because of the Affordable Care Act, health insurers are required to provide you with an easy-to-understand summary about your benefits including mental health benefits, which should make it easier to see what your coverage is. More information also may be available with your state Consumer Assistance Program (CAP).

Answer: All state Medicaid programs provide some mental health services and some offer substance use disorder services to beneficiaries, and Children’s Health Insurance Program (CHIP) beneficiaries receive a full service array. These services often include counseling, therapy, medication management, social work services, peer supports, and substance use disorder treatment. While states determine which of these services to cover for adults, Medicaid and CHIP requires that children enrolled in Medicaid receive a wide range of medically necessary services, including mental health services. In addition, coverage for the new Medicaid adult expansion populations is required to include essential health benefits, including mental health and substance use disorder benefits, and must meet mental health and substance abuse parity requirements under MHPAEA in the same manner as health plans. For additional information on Medicaid and mental health and substance use disorder services, visit: Behavioral Health Services - Medicaid.gov

Medicare Part A (Hospital Insurance) covers inpatient mental health care services you get in a hospital. Part A covers your room, meals, nursing care, and other related services and supplies.

Medicare Part B (Medical Insurance) helps cover mental health services that you would generally get outside of a hospital, including visits with a psychiatrist or other doctor, visits with a clinical psychologist or clinical social worker, and lab tests ordered by your doctor.

If you get your Medicare benefits through a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan, check your plan’s membership materials or call the plan for details about how to get your mental health benefits.